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病史摘要;患儿女性,年龄5个月,住院号17403。因憋喘40余天伴发热加重一天于1980年4月27日入院。 入院检查:体温38℃,脉率160次/分,呼吸28次/分。头围39公分,身长55公分。发育正常,营养差。面色灰,鼻扇气促,唇发绀,桶形胸,串珠明显,两肺闻及散在的干、湿性罗音,肝肋下1.5厘米,脾未触及,神经系统检查未发现异常。实验室检查:白细胞总数23800,中性粒细胞81.0％,淋巴细胞17.0％,单核细胞2％。胸部透视;见右下肺内带渗出性片状阴影。临床诊断:支气管肺炎,佝搂病,营养不良Ⅱ度。
Summary of medical history; Children with children, age 5 months, hospital number 17403. Because of wheezing more than 40 days with fever heavier one day in April 27, 1980 admission. Admission examination: body temperature 38 ℃, pulse rate 160 beats / min, breathing 28 beats / min. Head circumference 39 cm, 55 cm long. Normal development, poor nutrition. Facial gray, nasal fan impetuosity, lip cyanosis, barrel chest, beaded obvious, both lungs scattered and scattered in the dry and wet rales, liver ribs 1.5 cm, spleen not touched, nervous system examination found no abnormalities. Laboratory tests: the total number of leukocytes 23800, 81.0% of neutrophils, lymphocytes 17.0%, monocytes 2%. Chest perspective; see the right lower lung with exudative patchy shadow. Clinical diagnosis: bronchial pneumonia, hug disease, malnutrition Ⅱ degrees.